Health exam #1

An insured is covered under 2 group health plans - under his own and his spouse's. He had suffered a loss of $2,000. After the insured paid the total of $500 in deductibles and coinsurance, the primary insurer covered $1,500 of medical expenses. What amount, if any, would be paid by the secondary insurer?

$500 (the second insurer will cover what the first comany will not pay, such as DEDUCTIBLES AND CONINURANCE)

The max the insurance guaranty association will pay to an individual for life insurance death benefits is

$500,000

A producer received a group master policy and cerificates for delivery to the insured. Within how many days must the policy and certificates be delivered

10 calendar days (A calendar cost 10 dollars)

An insured pays a monthly premium of $100 for her health insurance. What would be the duration of the grae period under her policy?

10 days ( 7 days for weekly, 10 days for monthly, and 31 days for everything else)

Under the NJ temporary disability law, a "covered individual" is any person who is employed by a covered employer, or who has been out of work for less than

2 weeks

in a 12 month period, how many home health care visits must a health insurance policy provide for?

60

Under the uniform required provisions, proof of loss under a health insurance policy normal should be filed within

90 days of a loss

Which of the following policies is NOT required to include coverage for alcoholism

A medicare supplement policy (benefits for the treatment of alcoholism are covered in NJ; medicare supplement does not provide hospital or medical expense benefits)

A deductible is

A specific dollar amount that the insured must pay first before the insurance company will pay the benefits

Which of the following long term care benefits would provide coverage for care for functionally impaired adults on a less than 24 hour basis?

Adult day care

If an insurance company makes a statement that its policies are guaranteed by the existence of the Insurance Guaranty Association, that would be considered

An unfair trade practice (it is illegal to advertise, but the statement is still true and it would NOT be considered a misrepresentation)

What is the max period of time during which an insurer may contest fradulent misstatements made in a health insurance application?

As long as the policy is in force (no other misstatement made in the application at the time of issue will be used to deny a claim after the policy has been in force for 2 years)

Which of the following refers to nursing and other health care services rendered to a person in his or her residence on a part-time or intermittent basis?

Home health Care (nursing and other health care services rendered to a person in his or her residence)

Who makes up the Medial information Bureau?

Insurers (Men In Black are actually insurance agents)

Which of the following insurance coverages would be allowed with an MSA?

Long-term care

An insured is covered under a medicare polticy that provides a list of network healthcare providers that the insured must use to receive coverage. IN exchange for this limitation, the insured is offered a lower premium. Why type of medicare policy does the insured own?

MEdicare SELECT (requires specific healthcare providers and hospitals, except in emergency situations. in return the insured pays lower premium amounts)

Which of the following programs expands individual public assitance programs for people with insufficient income and resources?

Medicaid

An insurance producer is selling a medicare supplement policy to bob the applicant. Bob is worried that if his health changes, his policy will not be renewed. What can you tell him?

Medicare supplement policies are guaranteed renewable

A certification of license status must include all of the following information EXCEPT

Number of years a licensee has been in the business (licensee's date of birth, types of insurance licenses, and license reference number ARE include)

Which renewal option does NOT guarantee renewal and allows the insurance company to refuse renewal of a policy at any premium due date?

Optionally renewable

which of the following special policies covers unusal risks that are NOT noramlly included under Accidental Death and Dismemberment coverage?

Special Risk policy

An aent is in the process of replacing the insured's current health insurance policy with a new one. Which of the following would be a proper action

The old policy should stay in force until the new policy is issued (an agent must make sure that the current policy is not cancelled before the new policy is issued)

When can a health insurance policy exclude a person from coverage based on a genetic characteristic?

Under no circumstances (No individual or group health insurance policy providing hospital or medical expense benefits can exclude any person on the basis of an actual or expected health condition due to any genetic characterisitc)

According to the rights of renewability rider for cancellable policies, all of the following are correct about the cancellation of an individual insurance policy EXCEPT

Unearned premiums are retained by the insurance company (The unearned premium will be returned on a pro-rata basis)

If the insured under a disability income insurance policy changes to a more hazardous occupation after the policy has been issued, and a claim is filed, the insurance company should do which of the following

adjust the benefit in accordance with the increased risk

An agent makes a mistake on the application and then corrects his mistake by physically entering the necessary information. who must then initial that change?

applicant

under the NJ temporary disability law, a "covered individual" is any person who has been out of work for less than 2 weeks or who is employed by a

covered employer

in a relative value system of determining coverage for a given procedure, what term describes the total amount payable per point?

coversion factor

which type of insurance provides funds for a businesss organization to purchase the business interest of a disabled partner?

disability buy-sell

A waiver of premium provision may be included with which kind of health insurance policy?

disability income (in guaranteed renewable and noncancellable individual disability income policies which allows them to be excempt of payments during their period of disability)

An insured is hospitalized with a back injury. Upon checking his disability income policy, he learns that he will not be eligible for benefits for at least 30 days. This would indicate that his policy was written on a 30 day

elimination period (used to filter previous injuries that the insured is trying to file a claim for)

as it pertains to group health insurance. COBRA stipulates that

group coverage must be extended for TERMINATED employees up to a certain period of time at the former employee's expense

Rob is being treated by a physical therapist in his appartment for a disorder which if he were not treated there, would have to be treated on an impatient basis in the hospital. what kind of care is this?

home health care

which of the following entities has the authority to make changes to an insurance policy?

insurer's executive officer

which of the following is NOT true regarding a certificate of authority

it is issued to group insurance participants

which of the following is true regarding a term health policy?

it is nonrenewable

Which of the following is INCORRECT concerning MEDICAID?

it is soley a federally administered program

What significance did paul vs virginia have on the insurance industry

it was decided that insurance was NOt interstate commerce and could not be regulated by the federal goverment

Which of the following provisions would prevent an insurance company from paying a reimbursement claim to someone other than the policyowner?

payment of claims (payment of claims provision states that the claims must be paid to the policyowner, unless the death proceeds need to be paid to a beneficiary)

which renewability provision are you most likely to see on a travel accident policy?

period of time (the policy will only last a certain period of time and cannot be renewed. A travel accident only policy will only provide coverage during the dates the insured is traveling)

Regarding the taxation of business overhead policies

premiums are deductible, and benefits are taxed

insurers may change which of the following on guaranteed renewable health insurance policy?

rates by class (the insurer may increase premiums on a class basis only and not on an individual policy)

When an insurer combines two periods of disability into one, the insured must have suffered a

recurrent disability

Which provision states how much time must pass between two like illnesses in order for the second one to be covered under a new set of benefits

recurrent disability provision

all of the following term-term care coverages would allow on insured to receive care at home EXCEPT

skilled care (custodial care, respit care, home health care, and adult day care are all coverages used to reduce the necessity of admission into a care facility. skilled care is always provided in an institutional setting)

which of the following accurately describes group disability income insurance?

the extent of benefits is determined by the insured's income

An insurer hires an advertising agency to create an advertisement for a health insurance policy. The public complains that the way the advertisement presents the policy is misleading because of certain photographs that the advertiser put on the commercial. Who will be held liable for this?

the insurer (The advertiser--> insurer)

which of the following is NOT true regarding partial disability?

the is a form of insurance that covers part-time workers (partial disability covers full-time working insureds who are unable to perform some, but not all, of their regular job duties or can no longer work full time resulting in loss of income. Payment from partial disability is typically 50% of the total disability benefit)

the insuring clause of a disability policy usually states all of the following EXCEPT

the method of premium payment (it does include: identities of the insurance company and the insured, that insurance against loss is provided, the types of losses covered)

Which of the following best describes the purpose of coordination of benefits regulation?

they discourage overinsurance and avoid duplication of benefits by permitting a reduction of benfits when a person is covered by more than one plan

Which of the following statements is CORRECT about social security?

to be eligible, one must meet certain requirements (a person must have been employed in a job that is covered under social security, or the spouse of a deceased covered worker)

in forming an insurance contract, when does accpetance usually occur?

when an insurer's underwritter approves coverage